Inappropriate Medications Prescribed Among Patients on Dialysis

Armando Silva Almodovar, PharmD, MPH

Credit: LinkedIn

Patients with end-stage kidney disease (ESKD) receiving maintenance hemodialysis are often prescribed medications that are contraindicated, supra-therapeutically dosed, or potentially unnecessary, according to findings from a retrospective longitudinal cohort study.¹

Leveraging patient information from the United States Renal Data Systems database, results showed nearly 30% of patients were exposed to potentially inappropriately prescribed medications at the start of dialysis and > 20% were still receiving these medications after 1 year of dialysis.¹

According to the US Centers for Disease Control and Prevention, about 35.5 million adults in the US have chronic kidney disease and may eventually progress to kidney failure. In 2020, nearly 808,000 people in the US were living with ESKD, 69% of whom were on dialysis.²

“Patients with ESKD being treated with dialysis are especially vulnerable to toxicity from medications excreted by the kidneys and those that are non-dialyzable,” wrote Armando Silva Almodovar, PharmD, MPH, research pharmacist at the Ohio State University College of Pharmacy, and colleagues.¹ “Few studies have examined the prevalence of exposure to [potentially inappropriately prescribed medications] among patients with ESKD receiving maintenance hemodialysis.”

Seeking to address this gap in research, investigators conducted a retrospective longitudinal cohort analysis of patients represented in the United States Renal Data Systems database examining the prescribing of medications at the start of hemodialysis and quarterly up to 1 year later. For inclusion, patients were required to be enrolled in Medicare Part D for ≥1 year before starting hemodialysis, >65 years of age, start chronic hemodialysis in 2018, and have evidence of prescribed medications at the start of hemodialysis.¹

Investigators considered medications potentially inappropriately prescribed if they were recommended to be avoided, discontinued, or contraindicated in the setting of maintenance hemodialysis, or if the average daily dose of a claim exceeded the maximum daily dose utilizing recommendations derived from Lexicomp.¹

A total of 33,882 patients were included in the analysis. Among the cohort, patients were predominantly between 66-84 years of age (89%), male (53%), White (72%), did not identify as Hispanic (87%), were located in areas with urban zip codes (85%), and lived in areas where the social deprivation index score exceeded 50 (57%). Diabetes and hypertension were prevalent among 89% and 63% of patients, respectively.¹

Potentially inappropriately prescribed medications were identified among 29.6% (95% CI, 29.1%-30.1%) of patients who initiated hemodialysis in 2018. By the end of the first year, 21.9% (95%CI, 21.4%-22.4%) of patients were still exposed to medications that were contraindicated, supra-therapeutically dosed, or potentially unnecessary in the first year of dialysis services.¹

The most common medications potentially inappropriately prescribed for the greatest percentage of patients were gabapentin (5.2%; 95% CI, 5.0-5.4%), hydrochlorothiazide (4.6%; 95% CI, 4.4-4.8%), famotidine (3.6%; 95% CI, 3.4-3.8%), glimepiride (3.4%; 95% CI, 3.3-3.6%), and rosuvastatin (2.6%; 95% CI, 2.4-2.8%).¹

Investigators outlined several potential limitations to these findings. These included, but were not limited to, a lack of data to evaluate prescribers’ rationale for the perceived benefits versus risks of prescribing potentially inappropriate medications, a potential underestimated exposure due to only including medications overlapping with specific points in time, and underestimation of over-the-counter medication attributed to reliance on claims data.¹

“Findings from this study reveal the need to implement medication management programs specifically targeting patients receiving hemodialysis,” investigators concluded.¹

References:

1. ^{Almodovar AS, Donneyong M, Seiber E, et al. Potentially Inappropriately Medication Prescriptions Among Medicare Patients Receiving Hemodialysis. American Journal of Kidney Diseases. https://doi.org/10.1053/j.ajkd.2023.11.012}
2. ^{US Centers for Disease Control and Prevention. CKD-Related Health Problems. Chronic Kidney Disease Initiative. June 5, 2023. Accessed February 15, 2024. https://www.cdc.gov/kidneydisease/publications-resources/annual-report/ckd-related-health-problems.html}